Monthly Premiums
| Plan Option* | Employee | Family | Employee + Spouse | Employee + Child(ren) |
|---|---|---|---|---|
| Plan 1 | $609 | $2008 | $1217 | $1035 |
| Plan 2 | $548 | $1808 | $1096 | $931 |
| Plan 3 | $426 | $1406 | $852 | $724 |
| Plan 3 (with HRA) | $452 | $1490 | $903 | $767 |
| Plan 4 | $419 | $1384 | $839 | $713 |
| Plan 4 (with HRA) | $444 | $1467 | $889 | $756 |
* To determine the deductible amounts, out-of-pocket maximums, and coinsurance percentages for each plan option, please consult the detailed chart below.
Rates effective for rate region 1.
| Plan | Plan 1 | Plan 2 | * Plan 3 | Plan 4 |
|---|---|---|---|---|
| Medical Deductible Individual | $500 | $1000 | $3000 | $3500 |
| Medical Deductible Family | $1000 | $2000 | $6000 | $7000 |
| Member Cost Share (Co-Insurance) for Covered Medical Expenses After Deductible | 10% In-Network 30% Non-Network | 15% In-Network 30% Non-Network | 20% In-Network 30% Non-Network | 20% In-Network 50% Non-Network |
| Medical Out-of-Pocket Maximum Individual | $1500 | $3000 | $5100 | $6000 |
| Medical Out-of-Pocket Maximum Family | $3000 | $6000 | $10200 | $12000 |
| Rx Out-of-Pocket Maximum Individual | $1000 | $1000 | Applied to Medical Deductible; then Plan pays 100% | $500 |
| Rx Out-of-Pocket Maximum Family | $2000 | $2000 | Applied to Medical Deductible; then Plan pays 100% | $1000 |
| Total Plan Out-of-Pocket Maximum Individual | $2500 | $4000 | $5100 | $6500 |
| Total Plan Out-of-Pocket Maximum Family | $5000 | $8000 | $10200 | $13000 |
* Please note: Plan 3 is a Health Savings Account (HSA)-compliant High Deductible Health Plan (HDHP). Benefits and coverage under Plan 3 may be different from other plan options. Please consult the Plan 3 Summary Plan Description for additional details or contact the Benefit Plans Office.